S 2273 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUo.DING-ELp:crRICAL PEIy IT No. 2273 273
BUILDING DIVISION APPLICATIONAIERMIT 1'IAhIHINC-hfECi1ANICAL
BUILDING PROJECT IDENTIFICATION
RIIII.IIINGADDI s.. SANITARY NO. APPLICATION SUBMITTAL.DA]00 7 - ko
O N AMI:: C RA.I :S N LIC NO: y�o
02� � NIC C(INTR Lif
�ARCHI'IT.CI'd3NGiNF.ER: LIC NO: 91>O�SS: ^Gi ❑
1 q1 +lam
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Is Cx
El 'E-1 ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERM IT FEE
I hereh,alrmt that 111.11,]sensed node,rood....,..mf Qopm,v(commencing JOII DESCRIPTION
ams who Section 9o(N)nn Divisionfor me Rosiness omit Profesdon.G,le,and mylieen.e ie RESIDENTIAL:
00 in full lose xnA elle /' VERMN ISSUANCE
=Ur License rte, — LIC.M 2 ❑SFUWL ❑KITCHEN RE MODEL
Rub APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N 6 L Dam C.naa or _
(..Oy ARCIIIi'ECTSDE'.. RATION PANELS ❑MULTI-UNIT ❑$TRUCfURAI.
Oz=Z^ andira Pm)Tplans h be ux 5pu�lic ruillaJs MODIFICATION
DP'102MAMP'S (]INTERIOR ❑CHIMNEY REPAIR
W Lic Pndcvsiomr 201-1000AMPS MPROVF.MENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IfxMIAMI!S BATH REMODF.IIREPAIR [3 DEMOLITION
C C 6 1 hereby affirm that 1 am exempt from the Commemr's License Law for the
'1 6 U (.]].wins reason.(Section 9031.5,Business and Profession.Code:Any idly or county SIGNS ELECIRICAL ❑OTHER �_
1+}+m y which re,ol n permm and
use.constmn,alter, ove,demolish,or repair ony slrucmrc
�vOQ..1 prior w its issmuIva,alsoregalres theaHlicam Gnsuch ledrul to fila a.isnedualcment SPECIAL CIRCUI'WMISC.
vWW11} tbmb.NliwnecJ pumuanu.lhe provisions of the Contrnfnrx Licemc Luw(Chapfer0
IyCoo (commencing will Section]OfNB.(Division Inflate Bodnessadd Professions 101c)or 'TEMP.METER OR POLP,INST.
a m o( that he is mennpf Therefrom..,[,he basis for the alleged esemptien.Any violation or NEW IIDITION ❑DEMOLITION
NSection 71111.3 by any applicantfor a permitsubjttt the applicant m a civilpenally of POWER DEVICES
not norabn five hundred dollars(5500). IE T ❑FOODSERVICE
Z} I ROVEhfE
OQ ❑I,as�wnerofthe progeny.ormynnployeeswithwagc.as theirs�leenrnpensafion, SWIMMING POOL ELECTRIC rr..�@ss
MIldothcwork,and the structure is notlmmnded.r.tourd forsale(Sea 9094,Ihtsiness T ;r
and Proociaons Code:The G Mason's License Law Joes oat apply It,un owner of OUTLETS—SWITCHES—FIXTURES
C'3 property who builds or Improve%thereon,and who dross ouch stuck himself or through
his own employees,provided that such improvements are not intended ar offered for NEN'RESIDENTIAL ELECTR SQ FT.
sale.IL however.the building orimpmvemem is sold within one giro of comgletion,the SQ.FT.FLOOR AREA 5/SQ,FT,
owner-builder will have The b odno of proving that he did not build or improve for pur-
pow"Coaled,
E]1,a.owner of the prnpany,:nn asdu wily contracting with licensed c.ntmdots 1. TOTAL'
rmff.m mo project(See.9044,linim,s and Prnlatl,wns Code:)Tra Connector.Li-
censa Law does no,apply inmost of property who tmildsm impmvcs thereon,and QTY, PLUMBING PERMIT FEE
who comms(,for such projects with a commefor(s)Ken
eed n
anaam to fhc Confran.rs
cense Law. PERMIT ISSUANCE
lame ndv, ca .R&I'CBnfhisreason
Owner Dwe —
ALTER—GRAIN&VEST—WATER(EA) VALUATIOfIN
W KER'S COMP,NSATION DECLARATION BACK FLOW PROTECT.DEVICE ^O vU
I hereby affirm under penalty of perjury one of the following declum]ions: J ✓
I have and will maintain a Certificate of Consent ulf-insure for Worker's Coal DRAINS—FLOOR.ROOF AREA,COND. STORIES TYPE CONSTRUCTION
section,as provided for by Section J]00.f The Lido,Gale,for the performance of the
work for which this permit is issued. FIXTURES—PERTRAP
❑1 have and will m timnln Worker's Compenmion Insurance,m required by Section ! I—M1
I]Wofthe Labor Code,fit,lhalwrlinnonceef the work for which dr,pction is i..ued. GAS—EA.SYSI'IiM-I INC.4 fIU'I'I,p1S OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS—IIA.SYSI'17M OVER 4(IIA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GRGSUINDl15TRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES _
('This section need oaf he mmplmeJ iffhe permit is fnronelnundred Anllun(EIIXq GREASE'IRAI'err ler.) PhANCHECK FEE
1,entythal in theperlimnance of The work fm vetudOhis permit is issued,I sial l S17WER—SAN['IAIV—STORM IIA,200 FT.
not cntp]ny any person in any frontier so uv to become subject to the Workers'Compen. ENERGY FEE
z .,,.a Lawsof Cali fomia.Date WATER HEAI'LR WNfXLECIR
O Applicant GRADING FEE
�-i
A NOTICETO APPLICANT If,after making this Certificate of Exemption,you should WATER SYM FIAT REATING
NFbecome subject to the Worker'.Compensation provisions of the labor Cale.youmust SOUS FEE
q „'may forthwith e.nnply with such provisions or this Penni]shall he deemed revoked. WATER SERV ICI:
W Q CONSTRUCTION LENDING AGENCY NEW RESIDF:N'I'IAL PLMB. SQ.FI'. PAII
0( hereby affirm mm]hero is ucnnsfrunion lendins asencY fonts pvrformana of Dam ceilo
11.
TCI
work for which this permit is issued(SecR],30Civ.CJ
Lenders Name TO
WLanders Addmss TOTAL:
3� I ecnlfy and I have read Thi4 application and state that fhc manse of nation is 11111. INO Ir..
h mrreat,I agree mcomply with all cif,aoil amnfyordinune,md,one Uwarelatinsln QTY. MECHANICAL PERMIT PEE
U building construction,and hereby uuthoriu representatives of this city nn en¢rupon the SEI MIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify unit keep harmless the City of Cupertino against EL CKYZLLE
liabilities, costs and eapuru
ces which may in anyway acce against said City ALTER OR ADD TO MECIT
ce of Lha granting of this permit. PLUMBING HEin c LICAN'I DERSTANDS AND WILL CQMPLY WITH ALI,NON-POINT' AIR HANDLING UNIT('10 I0JKX)CPM)
OURCE R EG L .AT[ONS. MECHANICAL FEL'
AIR HANDIANO UNIT(OVER 10,003 CFM) CONSTRUCTION TAX
Sign mApp teal 'ontbmtVo`r '//�••{'4/L•— Data ( EXHAUST 1100DOMMUCT) HOUSING MITIGATION FEE
HA9AR000S MATERIALS DISCLOSURE
WIIlthe ambranl or future huildingoccupanfaoro or handle hmmrlous material DEATING UN IT flO 1 Rpt,RTU) s
as defined by Ibe Cupertino Municipal Coda Collie,9.12,and the frolth and Safety
Code,Seeli.n 25532(a)7 HEATING UNI'((OVER I Of1,INt0 111 Ill o/s}�/p{/
❑Yes VENTILATION FAN(SINGLE RESID) PAID {�e.:g_
' 13 fc_ Rmeiptx
NTti the applicant m..mre ifirad occupant use equipment of devices which
emir havarJous air cnnmminanb as JelineJ by The❑uy Area Air Quality Management BOILER—COMP(JHP OR 100,IX))RTU) 'rOTAI:
DW11nll7 BOILER—COMP(OVER 1110,0001B1In r,
rcait the havWnux rnamriuls requirements umkr Chapter 6,95 of the Cali AIRCONDITIONER 1..fe Q ISSUANCE;DATE
is fiealfh Safety Code,Sections 25505,25511 onk255J4.I unJcnfeml thm if the NEW RESIIIIINTIALMECH. SQ.
m1dirgshssm atrremly havcaten hm it is my mspmsibifly to only the recupam
of The q m vtMdch nun n 't pri 'ssunntt nfa CeniBua dOceupanry.
uuWuria. ugcm Dole - TOTAL:6�2. i On SSUEDBY: —� �A�TJ A.1�t.Cxa
OFFICE